Request for (Additional) Service(s) – Devon Integrated Children’s Services
The following information is required to ensure consistent and equitable access to Integrated Children’s Services, so that decisions around accepting Requests can be made quickly, and in the presence of all the necessary information to complete clinical screening. If Early Help intervention has taken place please provide the Early Help Assessment (previously DAF1) and Request for Additional Services (previously DAF2a – My Plan) in place of sections 1 and 2 of this form. Please ensure that these evidence work that has already been undertaken to support the Child (note that this is a requirement for referral to our specialist Services)
Requests for Service that do not include the required supporting information/attached evidence will be returned to the Requestor for completion.
Items highlighted bold are required fields. Additional space for answering questions can be found on the last page.
SECTION 1A Child Information
Name of Child or Young Person:
Gender:
Date of Birth:
NHS Number:
Child’s Address:
Postcode:
Phone Number:
(Childs contact if appropriate)
Any known alternate family names? / Yes No
If yes, please give details:
GP Name and Practice:
Ethnicity:
Unique Pupil Number:
(Intended) School/educational Establishment:
First Language if not English:
Interpreter required: / Yes No
Religion/Belief:
Is the child/young person a carer for another family member? / Yes No
Anything known about
Legal Status: / Child in Care/Child Subject to a Child Protection Plan/
Child under an Interim Care Order/Child under a Care Order/guardianshipor other status (please describe)
Additional supporting information
(e.g. responsible placing Local authority):
Is there a legal plan (e.g. Supervision Order) in place? If Yes, please describe / Yes No Unknown
Reading/Writing/Comprehension within normal ranges for age:
(to help us when
communicating with the child) / Yes No Unknown
If no, please give details:
SECTION 1B Family Information – Parents/Carers
PRIMARY CONTACT / 2nd CONTACT
Name:
Relationship to Child:
Address (if different to child’s address as recorded above):
Post code:
Phone Number:
Mobile number:
Email:
Known alternate Family Names:
First Language if not English:
Interpreter required: / Yes No / Yes No
Member of Armed Forces: / Yes No / Yes No
Parental responsibility: / Yes No / Yes No
Additional Supporting Information (parents/carers):
Please ensure contact details for all adults with Parental Responsibility are defined above
(and if not, please add here):
Please confirm all adults with Parental Responsibility are aware of the Request?
Yes No
SECTION 1C Accessible Information
Please complete this section if you are making a request for yourself or as a parent/carer
Do you or your child have any special communication requirements? / You: Yes No
Your child: Yes No
Do you need a format other than standard print? / You: Yes No
Your child: Yes No
If yes, please specify: / Braille Yes No
Large print Yes No
Easy read Yes No
Other, please specify
Do you need a British Sign Language interpreter or advocate? / You: Yes No
Your child: Yes No
Can we support you to lipread or use a hearing aid or other communication tool? / You: Yes No
Your child: Yes No
SECTION 2 Request for Service(s) – Supporting Information
Where the information below is available within existing documentation, such as the
Early Help Request for Additional Services (previously DAF2a – My Plan), please simply reference this in the response. Please attach, or signpost if on Right for Children, the applicable documentation when submitting this Request.
Please list any existing diagnoses/ prescribed medications:
Please describe the child/young person’s current presentation/functional difficulties, to include the history, duration and severity of presentation:
How concerned are you
(the Requestor) about the presentation/difficulties
described above? / Not concerned A little concerned
Very concerned
Additional comment:
How concerned are the parents/carers about the
difficulties their child is experiencing? / Not concerned A little concerned
Very concerned
Additional comment:
Please describe your understanding of the child/young person’s awareness that they have a difficulty, and the impact this is having on their behaviour at home/school/in other environments (e.g. changes in behaviour, avoidance or frustration):
Are there any existing safeguarding issues, including any past and/or current concerns about domestic violence?
Please list all the professionals/agencies with which you, the child/young person and their family have engaged in relation to this problem before making this Request
(e.g. Health Visitor, Consultant, Psychologist, Social Care):
Please list and provide evidence in relation to the activities you have already completed to address/resolve the problem, and the outcome of those activities:
Please describe the needs/outcomes that have not been met by the above activities, indicating why, where this can be determined, and provide the supporting evidence:
Please describe the outcomes you have discussed with the child/young person/family that you hope to achieve as a result of this Request:
Please confirm that the child/young person/family have given consent to the Request for Services:
Yes No
Where a young person has given own consent, please advise whether parental agreement has also been recorded?
Yes No
Where the responsible adult is not aware, have all safeguarding issues been considered? Please comment:
Please indicate the primary service from which the child might require assessment and each item
you are submitting in support of your Request from the list below as evidence of Early Help.
If you are not sure what evidence is required, please check our website for the
required documentary criteria: http://www.Devon.IntegratedChildrensServices.co.uk
SUPPORTING DOCUMENTATION ENCLOSED
Completed Devon ICS Information Sharing Consent Form
Note this should be completed by the Parent/Carer/Young Person
Family Information and Assessment Early Help Assessment (or DAF1)
Early Help Request for Additional Services (or DAF2a – My Plan)
My Education, Health and Care Plan (EHCP)
Educational Psychology
Relevant Previous reports
Paediatrician, GP health reports
PRIMARY SERVICE REQUESTED
CAMHS
/ ADDITIONAL SUPPORTING INFORMATION
Interventions already tried e.g counselling, school action plans, family support, public health nursing input, self-help (internet resources etc). Please provide details
Community Children’s Nursing
/ ADDITIONAL SUPPORTING INFORMATION
Nursing Assessments for Additional Care
Deaf Blind Guidance
Learning Disability Team / ADDITIONAL SUPPORTING INFORMATION
Evidence of diagnosis
Educational Psychology report
Evidence of previous attempts resolve the difficulties with mainstream support
Occupational Therapy / ADDITIONAL SUPPORTING INFORMATION
Confirmation that two terms of Fun Fit have been completed
Therapy/Nursing Assessments for equipment – where previously completed
Palliative Care
Portage / ADDITIONAL SUPPORTING INFORMATION
Please refer to requirements for Specialist Multi Disciplinary Assessment (MDA) for under 5s below
Rehabilitation Officer for Visually Impaired Children (ROVIC) / ADDITIONAL SUPPORTING INFORMATION
CVI (Certificate of Visual Impairment)
Social Care Disabled Children’s Service / ADDITIONAL SUPPORTING INFORMATION
Resource Allocation Assessment (RAS)
Individual Education Plan
Specialist Autistic Spectrum / ADDITIONAL SUPPORTING INFORMATION
Developmental profiles
Behaviour Support
SBQ Social Behaviour Questionnaires
Communication and Interaction
Specialist Multi Disciplinary Assessment (MDA) for under 5s / ADDITIONAL SUPPORTING INFORMATION
For complex medical cases discharge summary or paediatric report only required
Most recent Ages and Stages
Setting report (i.e. Nursery, Play group, child minder)
Evidence of how professionals have tried to target areas of delay in the community
Evidence of delay in two developmental areas and impactplus ages and stages
Speech and Language Therapy
/ ADDITIONAL SUPPORTING INFORMATION
Let’s Talk More screening tool score and paperwork
Result from most recent hearing test/Audiology report
SLT Toolkit – summary/report of completed activities with outcomes
Speech Link/Language Link assessment - results and evidence of outcomes
Previous Speech and Language Therapy report(s)
Special Schools Resource Pack – Summary/report of completed activities, with outcomes
ENT report (for voice requests only)
Unsure
Confirmation and Signatures
I confirm that every effort has been made to address this Child / Young Persons Educational, Health and/or Social Care Needs from the resources available. The Child / Young Person’s needs have now reached a nature, severity and/or complexity that require an application to be made for additional intervention.
Name of Requestor (please print):
Signature:
Role/relation to child/young person:
Date of Request:
Contact email:
Contact phone number:
Contact address:
Once completed please send this form and accompanying documentation to our Single Point of Access, preferably by email.
Note that emails from the list below to are secure. If you do not have a secure email route please call us on 03300 245 321 or email us to request access to a secure email route.
.cjsm.net (Criminal and Justice) / .gcsx.gov.uk (Local Government/Social Services).gse.gov.uk (Central Government) / .gsi.gov.uk (Central Government including Department of Health)
.gsx.gov.uk (Central Government) / .hscic.gov.uk (The Health and Social Care Information Centre)
.mod.uk (Military) / .nhs.net (NHSmail)
.pnn.police.uk (Police) / .scn.gov.uk (Criminal and Justice)
Integrated Children’s Services
Single Point of Access Team
1a Capital Court
Bittern Road
Sowton Industrial Estate
Exeter EX2 7FW
Version 2.0 September 2017